Recurring concern

Failure to provide timely treatment for constipation and impacted faeces

Get email alerts

Request correction

First reported 22 Aug 2014•Latest report 12 Aug 2025

Definition

What this concern includes

Includes failures in the treatment process for clinically significant constipation or impacted faeces, including timely prescribing, administration, monitoring and escalation of indicated enemas, laxatives or comparable treatment.

Not included

Excludes bowel-monitoring or documentation failures when required constipation treatment itself was provided reliably.
Excludes generic delays in clinical treatment where constipation or impacted faeces is not the identified condition.
Excludes unrelated bowel conditions or treatment failures without a material constipation or faecal-impaction component.
Excludes failures occurring after appropriate constipation treatment has been provided when the remaining concern is solely follow-up or another downstream process.

Reports: 3
Individual concerns: 3
Date range: 2014–2025
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

BTCM Limited1

Essex Partnership University NHS Foundation Trust1

Royal Sussex County Hospital1

Swansea Bay University Local Health Board1

University Hospitals Sussex NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

12 Aug2025
Essex
Concerns raised1
1. Delays in managing clozapine constipation
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Disseminate the January 2025 updated clozapine policy across medical teams to strengthen constipation assessment, monitoring and documentation.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Deliver dedicated teaching on monitoring and documenting clozapine side effects.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Resmije Ahmetaj · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in managing clozapine constipation
Wider context from the report
“(5) Clozapine constipation was raised as a serious side effect such that there is a Trust policy to manage this matter. This was not dealt with within the Trust for Ms Ahmetaj, and it took two weeks to raise this for the GP to manage. This did not cause or contribute to Ms Ahmetaj’s death however there is a concern for the long delay for other patients. ”
Source location
Resmije Ahmetaj · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate the January 2025 updated clozapine policy across medical teams to strengthen constipation assessment, monitoring and documentation.

Verbatim wording from the response
“We can assure the court that the Trust provides staff with clear guidance in the Clozapine policy last issued in January 2025 on the assessment, monitoring, and documentation of Clozapine-related constipation. The updated policy from January 2025 has been disseminated widely across the medical teams, and a dedicated teaching session took place on 2nd of October 2025 to reinforce best practice in the monitoring and documentation of Clozapine side effects.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 5 · response
Published 14 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver dedicated teaching on monitoring and documenting clozapine side effects.

Verbatim wording from the response
“We can assure the court that the Trust provides staff with clear guidance in the Clozapine policy last issued in January 2025 on the assessment, monitoring, and documentation of Clozapine-related constipation. The updated policy from January 2025 has been disseminated widely across the medical teams, and a dedicated teaching session took place on 2nd of October 2025 to reinforce best practice in the monitoring and documentation of Clozapine side effects.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 5 · response
Published 14 August 2025
Open published response
19 Jul2023
Swansea and Neath Port Talbot
Concerns raised1
1. Failure to account for respiratory compromise when administering laxatives
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Remind medication prescribers to select, dispense and administer medicines correctly under NICE and BNF guidance, reinforcing safe maximum-dose awareness and pharmacist dosage scrutiny.
  Stated by Swansea Bay University Local Health BoardStated planned
AI-generated summary

Shane Luke West · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Shane Luke West was pronounced dead on 17 August 2018 at Morriston Hospital after multi-organ failure caused by cardiorespiratory arrest associated with abdominal distention from chronic constipation and fluid build-up from laxative treatment. The principal concerns were inconsistent records of laxative administration, difficulty assessing his condition due to his learning disability, and whether the risks of further abdominal distention and respiratory compromise were sufficiently appreciated when administering laxatives.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to account for respiratory compromise when administering laxatives
Wider context from the report
“I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dosage of laxatives. 1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018. 2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane's condition. 3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function. 4. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid ”
Source location
Shane Luke West · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Remind medication prescribers to select, dispense and administer medicines correctly under NICE and BNF guidance, reinforcing safe maximum-dose awareness and pharmacist dosage scrutiny.

Verbatim wording from the response
“Action 3.1: All staff that prescribe medications are to be reminded that the correct drug needs to be selected, dispensed, and administered in line with National Institute for Health & Care Excellence (NICE) and British National Formulary (BNF) Guidelines.”

Source location
Response from Swansea Bay University Health Board
Page 4 · response
Published 28 July 2023
Open published response
22 Aug2014
Brighton and Hove
Concerns raised1
1. Failure to prescribe and administer treatment for impacted faeces and constipation
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

MARTIN ARNOLD HILL · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

MARTIN ARNOLD HILL arrived at A & E on 28 March 2014 after approximately three days of confusion, abdominal pain and vomiting, with raised inflammatory markers. The concerns included delayed antibiotics, failures to refer him to the Critical Care Outreach Team when his NEWS was elevated, inadequate withdrawal treatment, failures in managing constipation, poor handover and communication, and serious omissions in the Medical Administration Record.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to prescribe and administer treatment for impacted faeces and constipation
Wider context from the report
“(4) When Mr. HILL arrived in A & E it was found that he was suffering from constipation with impacted faeces in his bowel. He was written up for an enema and the Doctor who saw him directed that he should be given laxatives. The latter were never written up for him and the former was never given. In the event, careful study of the notes showed that he opened his bowels for the first time on the evening of the 28th March 2014 but this information was not apparently noted by the Doctors who were still talking about constipation over the next 24 – 36 hours. This shows poor patient handover and poor communication between the shifts and poor note taking. ”
Source location
MARTIN ARNOLD HILL · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in managing clozapine constipation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to account for respiratory compromise when administering laxatives

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to prescribe and administer treatment for impacted faeces and constipation

Actions described in response 2

Actions described in response 1